Podcast
Questions and Answers
What action should the nurse take when a client has questions about their medication?
What action should the nurse take when a client has questions about their medication?
During evacuation of a group of clients from a medical unit because of a fire, what should the nurse do if they observe an ambulatory client walking alone toward the stairway?
During evacuation of a group of clients from a medical unit because of a fire, what should the nurse do if they observe an ambulatory client walking alone toward the stairway?
What should the nurse do after a needle stick occurs while removing the cap from a sterile needle?
What should the nurse do after a needle stick occurs while removing the cap from a sterile needle?
When emptying 350 mL of pale yellow urine from a client's urinal, what should the nurse do next?
When emptying 350 mL of pale yellow urine from a client's urinal, what should the nurse do next?
Signup and view all the answers
When administering medications through a feeding tube, what should the nurse do first?
When administering medications through a feeding tube, what should the nurse do first?
Signup and view all the answers
What should the nurse document when identifying placement of IV access in the client's right arm?
What should the nurse document when identifying placement of IV access in the client's right arm?
Signup and view all the answers
Which client statement indicates that the nurse should further assess the medication order?
Which client statement indicates that the nurse should further assess the medication order?
Signup and view all the answers
What action should the nurse implement when providing wound care instructions to a client who does not speak English?
What action should the nurse implement when providing wound care instructions to a client who does not speak English?
Signup and view all the answers
The court will allow the health care provider to make the decision to withhold informed consent under therapeutic privilege.
The court will allow the health care provider to make the decision to withhold informed consent under therapeutic privilege.
Signup and view all the answers
Which action is most important for the nurse to implement when obtaining a lie-sit-stand blood pressure reading on a client?
Which action is most important for the nurse to implement when obtaining a lie-sit-stand blood pressure reading on a client?
Signup and view all the answers
Which intervention is best for the nurse to implement when a client becomes angry while waiting for a break to smoke?
Which intervention is best for the nurse to implement when a client becomes angry while waiting for a break to smoke?
Signup and view all the answers
Which serum laboratory value should the nurse monitor carefully for a client who has had a nasogastric (NG) tube to suction for the past week?
Which serum laboratory value should the nurse monitor carefully for a client who has had a nasogastric (NG) tube to suction for the past week?
Signup and view all the answers
Which response is best for the nurse to provide to a client asking about drinking juice daily to prevent urinary tract infections (UTIs)?
Which response is best for the nurse to provide to a client asking about drinking juice daily to prevent urinary tract infections (UTIs)?
Signup and view all the answers
What respiratory rate should the nurse document after counting respirations over two different intervals?
What respiratory rate should the nurse document after counting respirations over two different intervals?
Signup and view all the answers
Which health promotion brochure is most important for a client newly diagnosed with arteriosclerosis?
Which health promotion brochure is most important for a client newly diagnosed with arteriosclerosis?
Signup and view all the answers
What should the nurse implement first when a client reports not having a bowel movement in two days?
What should the nurse implement first when a client reports not having a bowel movement in two days?
Signup and view all the answers
What instruction is most important for a nurse to provide to a client with redness in the sacral area?
What instruction is most important for a nurse to provide to a client with redness in the sacral area?
Signup and view all the answers
What action should the nurse take next after inserting a urinary catheter and seeing no urine in the tubing?
What action should the nurse take next after inserting a urinary catheter and seeing no urine in the tubing?
Signup and view all the answers
What is the best nursing action regarding confidentiality when discussing a client's depression?
What is the best nursing action regarding confidentiality when discussing a client's depression?
Signup and view all the answers
What should the nurse do first after a client reports insomnia despite following relaxation techniques?
What should the nurse do first after a client reports insomnia despite following relaxation techniques?
Signup and view all the answers
Which action should the nurse take when an older client expresses confusion after consenting to surgery?
Which action should the nurse take when an older client expresses confusion after consenting to surgery?
Signup and view all the answers
What is the priority assessment after an employee reports being struck by lightning?
What is the priority assessment after an employee reports being struck by lightning?
Signup and view all the answers
What action should the nurse take when parental consent for a medication has not been obtained for a minor?
What action should the nurse take when parental consent for a medication has not been obtained for a minor?
Signup and view all the answers
Which action by the nurse is best for a client who has difficulty falling asleep?
Which action by the nurse is best for a client who has difficulty falling asleep?
Signup and view all the answers
What priority action should the nurse take when a client states, 'I feel faint' and begins to fall?
What priority action should the nurse take when a client states, 'I feel faint' and begins to fall?
Signup and view all the answers
How should the nurse respond when a client requests a pain pill while laughing at a television program?
How should the nurse respond when a client requests a pain pill while laughing at a television program?
Signup and view all the answers
What is the best response by the nurse when an obese client expresses concern about her sexual relationship?
What is the best response by the nurse when an obese client expresses concern about her sexual relationship?
Signup and view all the answers
Based on the assessment finding of increased respiratory rate from 18 to 24 breaths/min, which intervention is most important for the nurse to implement?
Based on the assessment finding of increased respiratory rate from 18 to 24 breaths/min, which intervention is most important for the nurse to implement?
Signup and view all the answers
What should the nurse do first upon being assigned to care for a close friend in the hospital setting?
What should the nurse do first upon being assigned to care for a close friend in the hospital setting?
Signup and view all the answers
When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety?
When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety?
Signup and view all the answers
What intervention has the highest priority in decreasing a client's risk of infection with partial-thickness and full-thickness burns?
What intervention has the highest priority in decreasing a client's risk of infection with partial-thickness and full-thickness burns?
Signup and view all the answers
Which laboratory value is the most reliable indicator of chronic protein malnutrition?
Which laboratory value is the most reliable indicator of chronic protein malnutrition?
Signup and view all the answers
Which action should the nurse take if the operative permit is not signed and the client has questions about surgery?
Which action should the nurse take if the operative permit is not signed and the client has questions about surgery?
Signup and view all the answers
Which factor in a client's history poses the greatest threat for complications during surgery?
Which factor in a client's history poses the greatest threat for complications during surgery?
Signup and view all the answers
When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?
When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?
Signup and view all the answers
Which step(s) should the nurse take when administering ear drops to an adult client? (Select all that apply)
Which step(s) should the nurse take when administering ear drops to an adult client? (Select all that apply)
Signup and view all the answers
Which instruction should the nurse provide to ensure optimal benefits from the use of a metered-dose inhaler?
Which instruction should the nurse provide to ensure optimal benefits from the use of a metered-dose inhaler?
Signup and view all the answers
Which action should the nurse take first when a client refuses to shower during their period?
Which action should the nurse take first when a client refuses to shower during their period?
Signup and view all the answers
What is the best response by the nurse when a client notes a reduction in sexual drive due to medication side effects?
What is the best response by the nurse when a client notes a reduction in sexual drive due to medication side effects?
Signup and view all the answers
What should the nurse do next after a comatose client winces and pulls away from a painful stimulus?
What should the nurse do next after a comatose client winces and pulls away from a painful stimulus?
Signup and view all the answers
The nurse plans to administer diazepam, 4 mg IV push. How many milliliters should the nurse administer?
The nurse plans to administer diazepam, 4 mg IV push. How many milliliters should the nurse administer?
Signup and view all the answers
Which intervention(s) is(are) correct when inserting a nasogastric tube for a client with hyperemesis? (Select all that apply)
Which intervention(s) is(are) correct when inserting a nasogastric tube for a client with hyperemesis? (Select all that apply)
Signup and view all the answers
Which observation indicates that a caregiver has learned how to use a gait belt for a client with right-sided weakness?
Which observation indicates that a caregiver has learned how to use a gait belt for a client with right-sided weakness?
Signup and view all the answers
Which nursing diagnosis has the highest priority when planning care for a client with an indwelling urinary catheter?
Which nursing diagnosis has the highest priority when planning care for a client with an indwelling urinary catheter?
Signup and view all the answers
What client instruction is important for managing altered sleep patterns related to nocturia?
What client instruction is important for managing altered sleep patterns related to nocturia?
Signup and view all the answers
When performing sterile wound care, what is the best action if the saline solution labeled 'opened' is dated 48 hours prior?
When performing sterile wound care, what is the best action if the saline solution labeled 'opened' is dated 48 hours prior?
Signup and view all the answers
Based on the nursing diagnosis of risk for infection, what intervention is best for an older incontinent client?
Based on the nursing diagnosis of risk for infection, what intervention is best for an older incontinent client?
Signup and view all the answers
What is the best action for a nurse when unable to distinguish the point at which the first sound was heard during blood pressure measurement?
What is the best action for a nurse when unable to distinguish the point at which the first sound was heard during blood pressure measurement?
Signup and view all the answers
What action should the nurse take first if a client's blood pressure reading is 156/94 mm Hg?
What action should the nurse take first if a client's blood pressure reading is 156/94 mm Hg?
Signup and view all the answers
What is the most likely outcome of a malpractice lawsuit against a nurse who rendered aid after a motor vehicle collision?
What is the most likely outcome of a malpractice lawsuit against a nurse who rendered aid after a motor vehicle collision?
Signup and view all the answers
Regarding informed consent for a client diagnosed with metastatic cancer, which legal principle is likely to be upheld?
Regarding informed consent for a client diagnosed with metastatic cancer, which legal principle is likely to be upheld?
Signup and view all the answers
Which intervention should be included in the instruction to prevent complications of immobility?
Which intervention should be included in the instruction to prevent complications of immobility?
Signup and view all the answers
Which method is best for the nurse to evaluate the client's ability to perform a dressing change at home?
Which method is best for the nurse to evaluate the client's ability to perform a dressing change at home?
Signup and view all the answers
Which meal best meets the dietary needs of a client with cholecystitis?
Which meal best meets the dietary needs of a client with cholecystitis?
Signup and view all the answers
When bathing an uncircumcised boy older than 3 years, which action should the nurse take?
When bathing an uncircumcised boy older than 3 years, which action should the nurse take?
Signup and view all the answers
The nurse should anticipate which change when a client's prescription is changed from the PO to IV route?
The nurse should anticipate which change when a client's prescription is changed from the PO to IV route?
Signup and view all the answers
Which action should the nurse implement for an older client who has had abdominal surgery and is requesting to go to the bathroom?
Which action should the nurse implement for an older client who has had abdominal surgery and is requesting to go to the bathroom?
Signup and view all the answers
By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection?
By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection?
Signup and view all the answers
Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?
Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?
Signup and view all the answers
In assisting an older adult client prepare to take a tub bath, which nursing action is most important?
In assisting an older adult client prepare to take a tub bath, which nursing action is most important?
Signup and view all the answers
In taking a client's history, which stool characteristic should the nurse report to the health care provider as soon as possible?
In taking a client's history, which stool characteristic should the nurse report to the health care provider as soon as possible?
Signup and view all the answers
How should the nurse respond to a client who is very apprehensive about an IV line insertion?
How should the nurse respond to a client who is very apprehensive about an IV line insertion?
Signup and view all the answers
How should the nurse respond to a female client with terminal cancer who wishes to plan a party for her friends?
How should the nurse respond to a female client with terminal cancer who wishes to plan a party for her friends?
Signup and view all the answers
Which observation requires the nurse's intervention when a UAP takes a client's blood pressure in the lower extremity?
Which observation requires the nurse's intervention when a UAP takes a client's blood pressure in the lower extremity?
Signup and view all the answers
During a clinic visit, which assessment data should the nurse obtain when a mother reports her 7-year-old child has sleep difficulties?
During a clinic visit, which assessment data should the nurse obtain when a mother reports her 7-year-old child has sleep difficulties?
Signup and view all the answers
What should the nurse do when the IV rate for a dehydrated 2-year-old has slowed?
What should the nurse do when the IV rate for a dehydrated 2-year-old has slowed?
Signup and view all the answers
Which client is most likely to be at risk for spiritual distress?
Which client is most likely to be at risk for spiritual distress?
Signup and view all the answers
Which intervention is most important for a client at high risk for the development of postoperative thrombus formation?
Which intervention is most important for a client at high risk for the development of postoperative thrombus formation?
Signup and view all the answers
Which nonverbal action should the nurse implement to demonstrate active listening?
Which nonverbal action should the nurse implement to demonstrate active listening?
Signup and view all the answers
A seriously ill client requests help to die. What is the best response for the nurse?
A seriously ill client requests help to die. What is the best response for the nurse?
Signup and view all the answers
Which document should the nurse use to develop nursing guidelines for a mental health services department?
Which document should the nurse use to develop nursing guidelines for a mental health services department?
Signup and view all the answers
What action is most important for the nurse to implement for an adult male exhibiting flat affect and short answers after losing a life partner?
What action is most important for the nurse to implement for an adult male exhibiting flat affect and short answers after losing a life partner?
Signup and view all the answers
Which response by the nurse is likely to encourage an older adult to assume total responsibility for insulin self-administration?
Which response by the nurse is likely to encourage an older adult to assume total responsibility for insulin self-administration?
Signup and view all the answers
What should the client do if questions arise about their newly prescribed medication after getting home?
What should the client do if questions arise about their newly prescribed medication after getting home?
Signup and view all the answers
Study Notes
Client Safety When Turning
- Bed rails should be raised on the side opposite the nurse during client repositioning to prevent falls.
- Grasping limbs or improperly using turning techniques can cause injuries.
Infection Prevention in Burn Clients
- Handwashing is the most effective method to prevent infection in burn patients.
- Administration of plasma expanders and topical antibacterial creams are secondary measures.
Indicators of Malnutrition
- A low serum albumin level is a reliable indicator of chronic protein malnutrition.
- Serum transferrin has a shorter half-life and does not reliably indicate long-term deficiencies.
Preoperative Protocol
- The surgeon must be notified if the operative permit is unsigned, prioritizing consent and understanding.
- Patient questions regarding the procedure should be addressed by the surgeon prior to signing.
Risks in Surgery History
- Long-term anticoagulant use significantly increases the risk of surgical bleeding complications.
Safe Client Transfer Procedures
- Positioning the chair at a 45-degree angle enables safe transfers; support should be offered on the weak side.
- Clients should never be lifted under the axillae to prevent nerve damage.
Administering Ear Drops
- Clients should be positioned on their side and auricle pulled upward and outward for effective medication delivery.
- The dropper should be held approximately 1 cm above the ear canal.
Effective Inhaler Use
- Medication should be inhaled through the mouth concurrently with the inhaler's compression for optimal effect.
Promoting Hygiene During Menstruation
- Educating clients about personal hygiene during menstruation is crucial; their beliefs should be acknowledged.
Addressing Changes in Sexual Drive
- Asking open-ended questions about the client's concerns regarding sexual activity allows for effective communication.
Glasgow Coma Scale Response
- Documenting purposeful responses to pain is essential in neurologic assessments.
Medication Dosage Calculation
- Calculating medication doses accurately is critical (e.g., diazepam 4 mg IV push equals 0.8 mL).
Nasogastric Tube Insertion
- High Fowler's position and instructing swallowing are key steps in nasogastric tube placement.
Gait Belt for Ambulation Assistance
- Caregivers should stabilize clients by standing on the weak side and behind the client for secure support.
Prioritizing Infections with Catheters
- High risk for infection is the primary concern with indwelling urinary catheters.
Managing Nocturia
- Suggesting reduced fluid intake in the evening helps manage nocturia effectively.
Proper Use of Sterile Solutions
- Discard saline solutions labeled as opened beyond a 24-hour use limit to prevent contamination.
Infection Prevention for Incontinent Clients
- Maintaining standard precautions is vital in reducing infection risk among vulnerable clients.
Blood Pressure Measurement Challenges
- Deflating the cuff and waiting before reattempting ensures accurate blood pressure readings.
Blood Pressure Management
- Comparing to past readings helps assess the significance of new high blood pressure readings.
Good Samaritan Law Protection
- Actions taken in good faith at an emergency scene are typically protected from malpractice claims.
Informed Consent Legalities
- Healthcare providers must obtain informed consent; failure to do so can lead to negligence claims.
Client Monitoring During Blood Pressure Readings
- Ensuring client safety through observation during standing blood pressure measurements is critical.
Managing Client Frustration
- Reviewing the outdoor break schedule with the client can alleviate frustration regarding smoking breaks.### Nursing Actions and Rationale
- Reviewing the schedule for outdoor breaks is crucial for maintaining client trust and communication.
- Close monitoring of sodium levels is important for clients with prolonged NG suctioning due to potential fluid loss.
Patient Education
- Cranberry juice is effective in preventing urinary tract infections (UTIs) by reducing bacterial adherence to the bladder.
Respiratory Assessment
- Document the respiratory rate based on the most accurate count, which should not include interruptions from coughing.
Health Promotion
- Focus on decreasing cholesterol intake as it is a significant risk factor for arteriosclerosis, more so than other factors such as smoking cessation or stress management.
Client Emotional Support
- Engage directly with clients in distress to assess their situation and provide immediate support.
Bowel Movement Assessment
- Assess a client’s normal bowel patterns before implementing interventions for constipation.
Pressure Ulcer Prevention
- Encourage frequent position changes for clients to prevent pressure ulcers, particularly in wheelchair users.
Urinary Catheterization Procedure
- If urine is not produced during catheterization, leave the initial catheter in place and attempt a second catheterization to correctly locate the bladder.
Maintaining Client Confidentiality
- It is essential to discuss client issues in private to maintain confidentiality, avoiding discussions in public areas.
Sleep Promotion Techniques
- Assess a client's current sleep routine before introducing changes to their care plan for insomnia.
Postoperative Client Monitoring
- Assess neurological status if a client expresses confusion after signing a consent form to ensure understanding and legality of consent.
Initial Assessment Following Injury
- First assess the client's pulse rate and regularity after being struck by lightning due to the risk of electrical injury.
Medication Administration for Minors
- Withhold medication from minors until proper parental consent is obtained, ensuring documented reasoning for the decision.
Enhancing Sleep Hygiene
- Incorporate a client's typical bedtime routine into their care plan to improve sleep quality.
Fall Prevention in Clients
- Prioritize gently lowering a client who feels faint to the floor to prevent injury rather than seeking immediate medical assessment.
Pain Assessment
- Utilize a pain scale to evaluate a client's pain experience, guiding appropriate medication administration.
Addressing Client Concerns
- Invite clients to share specific concerns to facilitate open communication and effective counseling regarding sensitive topics like sexuality.
Respiratory Rate Interventions
- Investigate the cause of tachypnea in postoperative clients, prioritizing the assessment of pain, anxiety, or fluid accumulation.
Professional Boundaries
- Communicate openly with charge nurses about assignments involving close friends to maintain professional boundaries.
Immobility Complications Prevention
- Perform range-of-motion exercises with immobile clients to reduce the risk of contractures and other complications.
Client Competence Evaluation
- Assess a client's ability to perform self-care tasks like dressing changes through direct observation for accuracy.
Nutrition and Dietary Needs
- Recommend low-fat foods for clients with cholecystitis to manage their dietary restrictions.
Hygiene Practices for Children
- Gently retract the foreskin in uncircumcised boys over three years for proper cleaning to prevent infection.
Pharmacokinetics of Medication Routes
- Transitioning medications from PO to IV can lead to a faster onset of action, as IV administration eliminates the absorption phase.### Patient Safety and Care
- Assist clients to the bathroom for safety; never leave them alone.
- Assess if clients need to void or have bowel movements, ensuring all safety measures are in place.
- Bedpans may not be necessary if safety can be maintained.
Chain of Infection
- Contaminated gloves can impact the mode of transmission in the chain of infection.
Preventing Venous Thrombosis
- Instruct clients with limited mobility to dorsiflex and plantarflex their feet hourly to promote venous return. Other strategies like deep breathing, repositioning in bed, and hydration help but are less effective for this purpose.
Bath Preparation for Older Adults
- Prioritize safety by checking the temperature of bath water for older adults to prevent burns or chills.
Stool Characteristics
- Black, sticky stool (melena) is a critical sign of gastrointestinal bleeding and requires immediate reporting to healthcare providers.
Client Apprehension
- Calmly reassure apprehensive clients about procedures, emphasizing that discomfort will be temporary.
Coping with Terminal Illness
- Supporting clients’ plans for joyous activities, like parties, is important as it encourages goals centered around pleasure despite terminal diagnoses.
Blood Pressure Measurement
- Apply a blood pressure cuff correctly to avoid inaccuracies; use the popliteal pulse when measuring in the lower extremities and expect a higher reading than in the arm.
Children's Sleep Patterns
- Address potential environmental factors contributing to sleep disturbances in school-age children showing resistance to bedtime.
Managing IV Fluids in Children
- Check for kinks and raise the IV pole to ensure proper IV flow in pediatric clients before taking further action.
Spiritual Distress Risk
- Clients facing ethical dilemmas, such as a Roman Catholic considering abortion, may be at higher risk for spiritual distress compared to those facing decisions aligned with their faith.
Preventing Postoperative Thrombus
- Encourage frequent ambulation for clients at risk of thrombus formation after surgery, as mobility is crucial for prevention.
Active Listening Techniques
- Demonstrate active listening by sitting facing clients, maintaining open body language, and ensuring eye contact.
Assessing Client Feelings
- When clients express feelings of despair, a nurse should assess their emotional state regarding death to provide appropriate support.
Mental Health Nursing Standards
- Use the ANA's Scope and Standards of Nursing Practice to develop guidelines for mental health nursing.
Grieving Process Support
- Refer clients in normal grieving to grief counseling, as it's an expected reaction to the loss of a loved one.
Encouraging Independence in Self-Care
- Reinforce clients’ capabilities in self-administering medication by acknowledging their successful demonstrations rather than their anxieties.
Medication Queries
- Advise clients to contact healthcare providers with any questions about medications for safe administration and individualized advice.
Emergency Fire Protocols
- During fire evacuations, ambulatory clients should be reminded to walk carefully down stairs instead of relying on wheelchairs or elevators.
Needle Stick Protocol
- After a needle stick incident, discard the involved needle and procure a new one; there’s no need to report if there was no contamination.
Urine Output Monitoring
- Record the volume of urine promptly, and if it's within normal limits, no additional action is needed unless other symptoms arise.
Medication Administration via NG Tube
- Always turn off suction before administering medications through a nasogastric tube to ensure full absorption.
IV Catheter Documentation
- Use precise terminology to document the placement of IV catheters, ensuring correct identification of the site used.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Description
Test your knowledge in nursing fundamentals with these HESI flashcards. Each flashcard presents a scenario focusing on client safety during patient handling. Perfect for nursing students preparing for exams.
